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Background & Aims Chronic pancreatitis (CP) is associated with osteopathy (osteoporosis or osteopenia). However, existing literature is mostly limited to retrospective or administrative studies that have not clearly defined the prevalence and risk factors. Our aim was to identify patient- and disease-related associations with osteopathy in a prospective cohort study of CP. Methods We studied 282 subjects with definitive CP enrolled in the PROCEED study who had a baseline dual-energy X-ray absorptiometry (DXA) scan. Osteopenia and osteoporosis were defined using the lowest T-scores. Clinical data were collected using standardized case report forms. Comparisons were performed with a multivariate logistic regression model with forward selection to identify risk factors for osteopathy. Results The majority of subjects had osteopathy on DXA scan (56.0%; 17.0% osteoporosis; 39.0% osteopenia). Subjects with osteopathy had a higher prevalence of traumatic (40.0% vs 26.4%; P = .02) and spontaneous fractures (3.9% vs 0; P = .04). On multivariate analysis, older age (odds ratio [OR], 1.29 per 5 years; 95% confidence interval [CI], 1.15–1.45), female sex (OR, 3.08; 95% CI, 1.75–5.43), white race (OR, 2.68; 95% CI, 1.20–6.01), and underweight body mass index category (OR, 7.40; 95% CI, 1.56–34.99) were associated with higher probability of osteopathy. There were no significant associations between osteopathy and other patient and disease-related features of CP. Conclusion In the largest study of patients with CP who underwent DXA screening, the majority had osteopathy. There are overlapping risk factors with osteopathy in the general population, but the high prevalence in men and younger women supports the need for future investigations into the mechanisms of bone loss in CP. ClinicalTrials.gov number, NCT03099850.

Return to Intended Oncologic Treatment (RIOT) has been proposed as a quality metric in the care of cancer patients. We sought to define factors associated with inability to RIOT in Pancreatic Ductal Adenocarcinoma (PDAC) patients.The NCDB was queried for patients who underwent pancreaticoduodenectomy for pathologic stage IB, IIA, or IIB PDAC from 2010 to 2016. Multivariable binary logistic regression models identified factors associated with failure to RIOT, and Kaplan-Meier survival analysis and Cox multivariable regression models demonstrated the impact of failure to RIOT on survival.Increasing age (p .001), Hispanic race (p = .002), pathological stage IB (p = .004) and IIA (p = .001) as compared to IIB, increasing hospital stay (p .001), and open surgical approach (p = .024) were associated with increased risk of inability to RIOT. Male sex (p .001), Charlson-Deyo scores of 0 (p .001) and 1 (p = .001) as compared to2, negative surgical margins (p = .048), receiving care at academic institutions (p = .001), and increasing institutional case volume (p = .001) were associated with improved odds of RIOT.Patient features can impact RIOT and should be considered when designing multi-modality treatment strategies.

Intraperitoneal drain placement decreases morbidity and mortality in patients who develop a clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). It is unknown whether multiple drains mitigate CR-POPF better than a single drain. We hypothesized that multiple drains decrease the complication burden more than a single drain in cases at greater risk for CR-POPF.The Fistula Risk Score (FRS), mitigation strategies (including number of drains placed), and clinical outcomes were obtained from a multi-institutional database of PDs performed from 2003 to 2020. Outcomes were compared between cases utilizing 0, 1, or 2 intraperitoneal drains. Multivariable regression analysis was used to evaluate the optimal drainage approach.A total of 4,292 PDs used 0 (7.3%), 1 (45.2%), or 2 (47.5%) drains with an observed CR-POPF rate of 9.6%, which was higher in intermediate/high FRS zone cases compared with negligible/low FRS zone cases (13% vs 2.4%, P.001). The number of drains placed also correlated with FRS zone (median of 2 in intermediate/high vs 1 in negligible/low risk cases). In intermediate/high risk cases, the use of 2 drains instead of 1 was not associated with a reduced rate of CR-POPF, average complication burden attributed to a CR-POPF, reoperations, or mortality. Obviation of drains was associated with significant increases in complication burden and mortality - regardless of the FRS zone.In intermediate/high risk zone cases, placement of a single drain or multiple drains appears to mitigate the complication burden while use of no drains is associated with inferior outcomes.

Background: The association between intraoperative estimated blood loss and outcomes after pancreatoduodenectomy has, thus far, been rarely explored. Methods: In total, 7,706 pancreatoduodenectomies performed at 18 international institutions composing the Pancreas Fistula Study Group were examined (2003-2020). High estimated blood loss (>700 mL) was defined as twice the median. Propensity score matching (1:1 exact-match) was employed to adjust for variables associated with high estimated blood loss and clinically relevant pancreatic fistula occurrence. The study was powered to detect a 33% clinically relevant pancreatic fistula increase in the high estimated blood loss group, with a = 0.05 and b = 0.2. Results: The propensity score model included 966 patients with high estimated blood loss and 966 patients with lower estimated blood loss; all covariate imbalantces were solved. Patients with high estimated blood loss patients experienced higher clinically relevant pancreatic fistula rates (19.4 vs 12.6%, odds ratio 1.66; P < .001), as well as higher severe complication rates (27.8 vs 15.6%), transfusions (50.1 vs 14.3%), reoperations (9.2 vs 4.0%), intensive care unit transfers (9.9 vs 4.8%) and 90-day mortality (4.7 vs 2.0%, all P < .001). High estimated blood loss was an independent predictor for clinically relevant pancreatic fistula (odds ratio 1.78, 95% confidence interval 1.37-2.32), as were prophylactic Octreotide administration (odds ratio 1.95, 95% confidence interval 1.46-2.61) and soft pancreatic texture (odds ratio 5.32, 95% confidence interval 3.74-5.57; all P < .001). Moreover, a second model including 1,126 pancreatoduodenectomies was derived including vascular resections as additional confounder (14.0% vascular resections performed in each group). On multivariable regression, high estimated blood loss was confirmed an independent predictor for clinically relevant pancreatic fistula reduction (odds ratio 1.80, 95% confidence interval 1.32-2.4 4; P < .001), whereas vascular resection was not (odds ratio 0.64, 95% confidence interval 0.34-1.88; P 1/4 .156). Conclusion: This study better establishes the relationship between estimated blood loss and outcomes after pancreatoduodenectomy. Despite inherent contributions to blood loss, its minimization is an actionable opportunity for clinically relevant pancreatic fistula reduction and performance optimization in pancreatoduodenectomy. Accordingly, practical insights are offered to achieve this goal. (c) 2021 Elsevier Inc. All rights reserved.

Objective To provide guidance on culturally competent contraception counselling that is free of coercion and promotes shared decision-making and patient autonomy. Target population Individuals of reproductive age who seek contraception or counselling for family planning. Options Contraception counselling is provided within a rights-based family planning framework, where the individual's beliefs, culture, preferences, and ability to use the chosen method are respected. Outcomes To promote patient autonomy in decision-making surrounding family planning, including the right to access and use their contraceptive method of choice, to decline contraception or use less effective methods of contraception, and to freely choose to discontinue a method of contraception, as well as the right to unbiased, non-coercive contraception counselling and evidence-based information from their health care provider Benefits, Harms, and Costs Implementation of these recommendations would reduce real or perceived coercive contraceptive care, particularly among vulnerable populations, resulting in improved patient autonomy and a better patient experience in health care settings. Evidence Databases searched: MEDLINE, Cochrane, PubMed, and CanLII. Medical terms used: contraception, family planning services, informed consent, coercion, decision making, sterilization, permanent contraception, counselling. Legal terms searched: forced sterilization, and aboriginal. Initial search conducted in 2020 and updated in 2021. Intended Audience This committee opinion is intended for health care providers (obstetricians, gynaecologists, family physicians, general surgeons, nurse practitioners, nurses, midwives, undergraduate/postgraduate medical trainees, and other health care providers) who provide sexual and reproductive health services.

RESUME Objectif Fournir des recommandations pour que le counseling contraceptif soit adapte a la culture, n'exerce aucune coercition et favorise la prise de decision partagee et l'autonomie de la patiente. Population cible Les personnes en âge de procreer qui consultent afin d'adopter une methode contraceptive ou d'obtenir des conseils en planification familiale. Options Le counseling contraceptif est offert dans un cadre de planification familiale fonde sur les droits de la personne, dans le respect des croyances, de la culture et des preferences individuelles et de la capacite de la personne a utiliser la methode choisie. Resultats Promouvoir l'autonomie de la patiente dans la prise de decisions concernant la planification familiale, y compris le droit d'obtenir et d'utiliser la methode contraceptive de son choix, de refuser la contraception ou d'utiliser une methode contraceptive moins efficace et de choisir librement de cesser l'utilisation d'une methode contraceptive, tout en s'assurant que le fournisseur de soins de sante lui offre un counseling contraceptif impartial et non coercitif ainsi que des renseignements fondes sur des donnees probantes. Benefices, risques et couts La mise en œuvre des recommandations limiterait la prestation de soins contraceptifs coercitifs, reels ou percus, en particulier chez les populations vulnerables, ce qui se traduirait par une amelioration de l'autonomie et de l'experience de la patiente dans les milieux de soins. Donnees probantes Bases de donnees utilisees : Medline, Cochrane, PubMed et CanLII. Termes medicaux utilises : contraception, family planning services, informed consent, coercion, decision making, sterilization, permanent contraception, counselling. Termes juridiques utilises : forced sterilization et aboriginal. La recherche initiale a ete effectuee en 2020 et mise a jour en 2021. Professionnels concernes : Cette opinion de comite est destinee aux fournisseurs de soins de sante (obstetriciens, gynecologues, medecins de famille, chirurgiens generalistes, infirmieres praticiennes, infirmieres, sages-femmes, stagiaires en medecine [externat, residence et monitorat] et autres fournisseurs de soins) qui offrent des services de sante sexuelle et reproductive.

Pain is a cardinal symptom of chronic pancreatitis (CP). Using Patient-Reported Outcomes Measurement Information System (PROMIS) measures, we characterized physical and mental health and symptom profiles of a well-defined cohort of individuals with CP and compared them with control subjects. Among patients with CP, we also examined associations between pain (intensity, temporal nature) and PROMIS symptom profiles and the prevalence of clinically significant psychological comorbidities.We analyzed baseline data in 488 CP patients and 254 control subjects enrolled in PROCEED (Prospective Evaluation of Chronic Pancreatitis for Epidemiologic and Translational Studies), an ongoing longitudinal cohort study. Participants completed the PROMIS-Global Health, which captures global physical and mental health, and the PROMIS-29 profile, which captures 7 symptom domains. Self-reported pain was categorized by severity (none, mild-moderate, severe) and temporal nature (none, intermittent, constant). Demographic and clinical data were obtained from the PROCEED database.Pain was significantly associated with impairments in physical and mental health. Compared with participants with no pain, CP participants with severe pain (but not mild-moderate pain) had more decrements in each PROMIS domain in multivariable models (effect sizes, 2.54-7.03) and had a higher prevalence of clinically significant depression, anxiety, sleep disturbance, and physical disability (odds ratios, 2.11-4.74). Similar results were noted for constant pain (but not intermittent pain) for PROMIS domains (effect sizes, 4.08-10.37) and clinically significant depression, anxiety, sleep disturbance and physical disability (odds ratios, 2.80-5.38).Severe and constant pain are major drivers for poor psychological and physical health in CP. Systematic evaluation and management of psychiatric comorbidities and sleep disturbance should be incorporated into routine management of patients with CP. (ClinicalTrials.gov, Number: NCT03099850).

Patient centered outcomes pertain to a patient's beliefs, opinions and needs in conjunction with a clinician's medical expertise and assessment. The rise of patient-centered outcome (PCO) measurement parallels increased interest in patient-centered care. PCO measures offer the opportunity for more meaningful measurement of health outcomes informative enough to guide treatment decisions. However, it has been suggested that, for practical and scientific reasons, existing PCO measures are currently not capable of delivering the kind of quality assured measurement required for high-stakes decision making. Potential solutions include: addressing the lack of units in PCO measurement through recourse to mathematical models devised to define meaningful, invariant, and additive units of measurement with known uncertainties; establishing coordinated international networks of key stakeholders guided by five principles (i.e., collaboration, alignment, integration, innovation and communication); better use of technology leveraging measurement through item banks linking PCO reports via common items, common patients, or specification equations based in strong explanatory theory. And finally ensuring PCO measurement always is associated with: (1) a clear definition of the measurand in regards to the intended clinical use; (2) a clear definition of the clinically allowable error of measurement; (3) international cooperation and consensus to navigate the complexities of the development of metrologically sound reference measurement systems; and (4) continued clinical validation of newly calibrated measures. In this article, we illustrate the principles to improve PCO measures with examples from breast cancer, vision-related patient-reported outcome measures, and dementia clinician-reported and performance outcome measures.

Early drain removal when postoperative day (POD) one drain fluid amylase (DFA) was ≤5000 U/L reduced complications in a previous randomized controlled trial. We hypothesized that most surgeons continue to remove drains late and this is associated with inferior outcomes.We assessed the practice of surgeons in a prospectively maintained pancreas surgery registry to determine the association between timing of drain removal with demographics, comorbidities, and complications. We selected patients with POD1 DFA ≤5000 U/L and excluded those without drains, and subjects without data on POD1 DFA or timing of drain removal. Early drain removal was defined as ≤ POD5.Two hundred and forty four patients met inclusion criteria. Only 90 (37%) had drains removed early. Estimated blood loss was greater in the late removal group (190 mL versus 100 mL, P = 0.005) and pathological findings associated with soft gland texture were more frequent (97 [63%] versus 35 [39%], P 0.0001). Patients in the late drain removal group had more complications (84 [55%] versus 30 [33%], P = 0.001) including pancreatic fistula (55 [36%] versus 4 [4%], P 0.0001), delayed gastric emptying (27 [18%] versus 3 [3%], P = 0.002), and longer length of stay (7 d versus 5 d, P 0.0001). In subset analysis for procedure type, complications and pancreatic fistula remained significant for both pancreatoduodenectomy and distal pancreatectomy.Despite level one data suggesting improved outcomes with early removal when POD1 DFA is ≤ 5000 U/L, experienced pancreas surgeons more frequently removed drains late. This practice was associated with known risk factors (estimated blood loss, soft pancreas) and may be associated with inferior outcomes suggesting potential for improvement.

Background Identification of incidental pancreatic lesions is increasing because of advancements in imaging. Diagnosis remains a challenge for clinicians, with intrapancreatic accessory spleens (IPAS) posing a unique dilemma. IPAS are frequently resected because of inability to exclude alternate diagnoses, subjecting patients to unnecessary risk. The purpose of this study was to examine our institutional experience with IPAS and develop a multidisciplinary algorithm to improve preoperative diagnosis. Materials and methods Patients who underwent a distal pancreatectomy at a single institution from 2005 to 2018 were identified from a prospectively maintained database. Examination of final pathology for a diagnosis of IPAS yielded the final cohort. Demographics, preoperative workup, and operative course were reviewed and analyzed. A diagnostic algorithm was composed based on the consensus of a panel of expert pancreatic surgeons, a radiologist, and a pathologist. Results Ten patients of 303 patients who underwent a distal pancreatectomy were identified with a final pathology of IPAS. The average age was 54 y, 80% were white, and 60% were male. Lesions ranged in size from 7 mm to 5.1 cm in largest diameter (mean 2.2 cm). Lesions were described as round, well-marginated, and enhancing masses within the pancreatic tail. Preoperative workup was variable in terms of imaging and laboratory testing. Diagnostic workups were examined and combined with multidisciplinary input to create a diagnostic algorithm. Conclusions Incidental pancreatic lesions like IPAS remain a diagnostic challenge for clinicians. Employing a diagnostic algorithm as proposed may aid in the distinction of malignant and premalignant pathology and prevent unwarranted pancreatic resections.

Pancreatic ductal adenocarcinoma (PDAC) is a highly malignant and lethal disease with few treatment options. Steroid receptor coactivator-3 (SRC-3, also known as NCOA3, AIB1, pCIP, ACTR, RAC3, TRAM1) sits at the nexus of many growth signaling pathways and has been pursued as a therapeutic target for breast, prostate and lung cancers. In this study, we find that SRC-3 is overexpressed in PDAC and inversely correlates with patient overall survival. Knockdown of SRC-3 reduces pancreatic cancer cell proliferation, migration and invasion in vitro. Additionally, inhibition of SRC-3 using either shRNA or a small molecule inhibitor can significantly inhibit tumor growth in orthotopic pancreatic cancer mouse models. Collectively, this study establishes SRC-3 as a promising therapeutic target for pancreatic cancer treatment.

Addition of en bloc segmental venous reconstruction (VR) to pancreaticoduodenectomy (PD) for venous involvement of pancreatic tumors increases the complexity of the operation and may increase complications. The long-term mesenteric venous patency rate and oncologic outcome has not been well defined.Our prospective database was reviewed to assess 90-day postoperative outcomes for patients who underwent PD or PD + VR (September 2004-June 2016). Two independent observers reviewed CT scans to determine long-term vein patency. In patients with pancreatic ductal adenocarcinoma, the impact of VR on 5-year overall survival was assessed using multivariate Cox proportional hazards regression. Student's t-test was used to evaluate continuous variables and the chi-square test for categorical variables.Three hundred ninety-three patients underwent PD (51 PD + VR). Patients undergoing PD + VR had longer operations (561 ± 119 versus 433 ± 89 min, P 0.00001) and greater blood loss (768 ± 812 versus 327 ± 423 cc, P 0.00001). There was no difference in 90-day mortality, overall postoperative complication rates, complication severity grades, reoperation, readmission, or length of stay. 26.7% experienced venous thrombosis. Most thromboses occurred in the first year after surgery, but we also observed late thrombosis in 1 patient after 89-month follow-up. Among 135 patients with pancreatic ductal adenocarcinoma, survival was significantly longer in the PD-alone group (31.3 months [95% confidence interval: 22.9-40.0] versus 17.0 [95% confidence interval: 13.0-19.1], pPD + VR does not increase short-term morbidity, but venous thrombosis is frequent and can occur long after surgery. Survival is inferior when VR is required especially in the absence of neoadjuvant chemotherapy.

Objective To establish national guidelines for the assessment of women's sexual health concerns and the provision of sexual health care for women. Evidence Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library from May to October 2010, using appropriate controlled vocabulary (e.g., sexuality, "sexual dysfunction," "physiological," dyspareunia) and key words (e.g., sexual dysfunction, sex therapy, anorgasmia). Results were restricted, where possible, to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Each article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by The Society of Obstetricians and Gynaecologists of Canada. Values The quality of evidence was evaluated and recommendations made using the use of criteria described by the Canadian Task Force on Preventive Health Care (Table).

BACKGROUND: Although used as criterion for early drain removal, postoperative day (POD) 1 drain fluid amylase (DFA) ≤ 5000 U/L has low negative predictive value for clinically relevant postoperative pancreatic fistula (CR-POPF). It was hypothesized that POD3 DFA ≤ 350 could provide further information to guide early drain removal. METHODS: Data from a pancreas surgery consortium database for pancreatoduodenectomy and distal pancreatectomy patients were analyzed retrospectively. Those patients without drains or POD 1 and 3 DFA data were excluded. Patients with POD1 DFA ≤ 5000 were divided into groups based on POD3 DFA: Group A (≤ 350) and Group B (> 350). Operative characteristics and 60-day outcomes were compared using chi-square test. RESULTS: Among 687 patients in the database, all data were available for 380. Fifty-five (14.5%) had a POD1 DFA > 5000. Among 325 with POD1 DFA ≤ 5000, 254 (78.2%) were in Group A and 71 (21.8%) in Group B. Complications (35 (49.3%) vs 87 (34.4%); p = 0.021) and CR-POPF (13 (18.3%) vs 10 (3.9%); p < 0.001) were more frequent in Group B. CONCLUSIONS: In patients with POD1 DFA ≤ 5000, POD3 DFA ≤ 350 may be a practical test to guide safe early drain removal. Further prospective testing may be useful.

SUMMARY High-content image acquisition is generally limited to cells grown in culture, requiring complex hardware and preset imaging modalities. Here we report an open source software package, OpenHiCAMM (Open Hi Content Acquisition for μManager), that provides a flexible framework for integration of generic microscope-associated robotics and image processing with sequential work-flows. As an example, we imaged Drosophila embryos, detecting the embryos at low resolution, followed by re-imaging the detected embryos at high resolution, suitable for computational analysis and screening. The OpenHiCAMM package is easy to use and adapt for automating complex microscope image tasks. It expands our abilities for high-throughput image-based screens to a new range of biological samples, such as organoids, and will provide a foundation for bioimaging systems biology., Graphical abstract

Objective The current research focuses on sexual risk behaviour among young adult Canadians who have not been vaccinated against HPV. Methods Six hundred and forty-six Canadian university undergraduates completed a self-administered survey assessing HPV vaccination status and sexual risk behaviour. Results Five hundred and thirty-seven participants (154 men and 383 women aged 17–23) who met eligibility criteria were analyzed. 48.5% (n = 185) of female and 89.6% (n = 138) of male participants had not been vaccinated against HPV. In the unvaccinated cohort, 51.4% (n = 95) of women were coitally experienced, 49.2% (n = 91) reported experience with oral sex, and 6.5% (n = 12) reported experience with receptive anal intercourse. 55.1% (n = 76) of men were coitally experienced, 22.5% (n = 31) of men reported receptive oral sex, and 2.9% (n = 4) of men reported receptive anal intercourse. Using validated sexual risk behaviour cut-offs, we determined that in the female unvaccinated population, the proportion at significantly increased risk for genital warts, cervical, anal, and oropharyngeal cancer was 11.0%, 30.0%, 6.5%, and 49.2% respectively. In the male unvaccinated population, the proportion at significantly elevated risk for genital warts and anal cancer was 27.2% and 2.9% respectively. Conclusion Unvaccinated young Canadian women and men commonly engaged in sexual risk behaviours for HPV infection, engaged in sexual risk behaviours at a similar level as their vaccinated counterparts, and a substantial number were at elevated risk of HPV related morbidities at a young age. Findings contribute to an evidence-based case for redoubling efforts to encourage HPV vaccination among unvaccinated young Canadians who are at risk of HPV infection.

Pancreatic ductal adenocarcinoma (PDAC) is among the deadliest types of cancer. The worldwide estimates of its incidence and mortality in the general population are eight cases per 100,000 person-years and seven deaths per 100,000 person-years, and they are significantly higher in the United States than in the rest of the world. The incidence of this disease in the United States is more than 50,000 new cases in 2017. Indeed, total deaths due to PDAC are projected to increase dramatically to become the second leading cause of cancer-related deaths before 2030. Considering the failure to date to efficiently treat existing PDAC, increased effort should be undertaken to prevent this disease. A better understanding of the risk factors leading to PDAC development is of utmost importance to identify and formulate preventive strategies. Large epidemiologic and cohort studies have identified risk factors for the development of PDAC, including obesity and type 2 diabetes mellitus. This review highlights the current knowledge of obesity and type 2 diabetes as risk factors for PDAC development and progression, their interplay and underlying mechanisms, and the relation to diet. Research gaps and opportunities to address this deadly disease are also outlined.

Ecologized learning situated in diverse in-school, out-of-school, and after-school contexts poses daunting challenges to measuring, communicating, managing, and improving outcomes. Formal and informal educators, policymakers, funders, and other key stakeholders engaged in cross-sector collaborations defined five pillars of STEM learning ecosystem success: partnerships, measures, administrative systems, teaching and learning practices, and workforce development connections. Variation in the ecosystem success construct was mapped, existing items from an earlier ecosystem assessment were revised, four parallel survey forms with common items were devised, and an online administration system was created in early 2020. Data from over 400 stakeholders in dozens of ecosystems were fit to a probabilistic model of measurement capable of supporting metrological quality assurance standards.

Projected increases in ocean pCO2 levels are anticipated to affect calcifying organisms more rapidly and to a greater extent than other marine organisms. The effects of ocean acidification (OA) have been documented in numerous species of corals in laboratory studies, largely tested using flow-through exposure systems. We developed a recirculating ocean acidification exposure system that allows precise pCO2 control using a combination of off-gassing measures including aeration, water retention devices, venturi injectors, and CO2 scrubbing. We evaluated the recirculating system performance in off-gassing effectiveness and maintenance of target pCO2 levels over an 84-day experiment. The system was used to identify changes in calcification and tissue growth in response to elevated pCO2 (1000 μatm) in three reef-building corals of the Caribbean: Pseudodiploria clivosa, Montastraea cavernosa, and Orbicella faveolata. All three species displayed an overall increase in net calcification over the 84-day exposure period regardless of pCO2 level (control + 0.28–1.12 g, elevated pCO2 + 0.18–1.16 g), and the system was effective at both off-gassing acidified water to ambient pCO2 levels, and maintaining target elevated pCO2 levels over the 3-month experiment.

Parental decision making about childhood vaccinations is complex and multidimensional. There is a perception that the number of parents having concerns regarding childhood vaccinations has been increasing in Canada. The aim of this study was to explore vaccine hesitancy among Canadian parents and to examine factors associated with a parent’s intention to vaccinate his/her child. Informed by the Theory of Planned Behaviour (TPB) this study assesses potential associations between parents’ knowledge, attitudes and beliefs toward vaccination and their intention to vaccinate their child in the future. A national sample of Canadian parents of children aged 24–59 months (N = 2013) was surveyed using an online survey methodology. Half of the surveyed parents strongly intended to have their child vaccinated in the future. Parents’ information needs and searches as well as parents’ trust in different institutions were associated with intention to vaccinate. Parents who reported having frequently looked for vaccine information, who considered that it was their role as parents to question vaccines, or who had previously experienced difficulty accessing vaccination services were less likely to strongly intend to vaccinate their child in the future. Parents who had a high level of trust in doctors and public health were most likely to strongly intend to vaccinate their child. Results of the multivariate analysis showed that positive attitudes (aOR = 8.0; 95% CI: 6.0, 10.4), higher perceived social support (aOR = 3.0; 95% CI: 2.3, 3.93), and higher perceived behavioural control (aOR = 1.8; 95% CI: 1.4, 2.43) were associated with parents’ intention to vaccinate their child. Findings of this study suggest that trust-building interventions that promote pro-vaccine social norms and that address negative attitudes toward vaccination could enhance vaccine acceptance among Canadian parents.

Policies to protect coastal resources may lead to greater social, economic, and ecological returns when they consider potential co-benefits and trade-offs on land. In Guanica Bay watershed, Puerto Rico, a watershed management plan is being implemented to restore declining quality of coral reefs due to sediment and nutrient runoff. However, recent stakeholder workshops indicated uncertainty about benefits for the local community. A total of 19 metrics were identified to capture stakeholder concerns, including 15 terrestrial ecosystem services in the watershed and 4 metrics in the coastal zone. Ecosystem service production functions were applied to quantify and map ecosystem service supply in 1) the Guanica Bay watershed and 2) a highly engineered upper multi-watershed area connected to the lower watershed via a series of reservoirs and tunnels. These two watersheds were compared to other watersheds in Puerto Rico. Relative to other watersheds, the Upper Guanica watershed had high air pollutant removal rates, forest habitat area, biodiversity of charismatic and endangered species, but low farmland quality and low sediment retention. The Lower Guanica watershed had high rates of denitrification and high levels of marine-based recreational and fishing opportunities compared to other watersheds, but moderate to low air pollutant removal, soil carbon content, sediment and nutrient retention, and terrestrial biodiversity. Our results suggest that actions in the watershed to protect coral reefs may lead to improvements in other ecosystem services that stakeholders care about on land. Considering benefits from both coastal and terrestrial ecosystems in making coastal management decisions may ultimately lead to a greater return on investment and greater stakeholder acceptance, while still achieving conservation goals.

It is well established that sedimentary margins grow by sediments bypassing through shelf- and slope-incising canyons onto the basin floor and by sediments being deposited incrementally across clinoforming and prograding margins. However, we argue that these two distinctive types of deep-water sediment supply to the basin floor and to the margin are generally not operating at the same time and should not be seen as integral parts of a single model. When shelf-incising canyons were actively bypassing sediments across the margin, the margin itself was not prograding, and vice versa. We present stratigraphic data for some 111 global examples of shelf- and slope-incising canyons and their linked basin-floor sediments, and we provide criteria to distinguish them from prograding margins fed by shelf-edge deltas and their linked slope channels and toe-of-slope fans. The defining character of the canyon feeding system is basin-floor sediment aggradation and the onlapping of this stratigraphy against an eroded basin margin. For many of our examples this onlap persists for millions to tens of millions of years and is especially prolonged in periods of persistent high eustatic sea level. This is in clear contrast to the downlapping stratigraphy that dominates during intervals of high sediment supply from the shelf, and active margin accretion. Some 60% of the ancient canyon/basin-floor fan systems are inferred to have been sourced by canyons tapping longshore drift in littoral cells; they are inferred because with canyon capture, tapped littoral cells are generally depleted and not preserved. In other cases, shelf-incising canyons tapped documented deltas on the inner or middle shelf, but in some other cases, a deltaic or riverine source was inferred. Canyon cutting and initial sediment bypass through the canyons are chiefly associated with initially ‘out-of-grade’ margins—for example, where a carbonate margin has foundered and oversteepened or where large-scale collapse of aggradational and oversteepened clastic shelf edges occurred. Canyon feeding onto the basin floor is linked with runout of basin-floor fans to the basin center, in contrast to direct-fed prograding margins, where sediment is continuously partitioned onto and across the entire shelf-edge, slope, and toe-of-slope areas.

Five moments in the formation and functioning of complex adaptive systems are: (1) emergent regularities and patterns in the flow of matter, energy, and/or information; (2) condensed schematic representations of these regularities enabling their identification; (3) reproductively interchangeable variants of these representations serving as templates for new instances of the pattern; (4) successful reproduction facilitated by the accuracy and reliability of the representations’ predictions of data flow regularities; and (5) informational feedback that adaptively modifies and reorganizes representations to incorporate new variations in the data flow, cycling back the first moment. These five moments are instantiated via stochastic models providing practical approaches to representing and managing complex adaptive psychological and social systems in education, health care, human resource management, etc. Local independence, unidimensionality, and statistical sufficiency criteria function as means of identifying, evaluating, and deploying conceptual and social forms of life acting as evolving agents in defined ecological niches. Bringing these agents into play systematically requires embodying them in technologies instrumental to making them readily recognizable and sharable across ecosystem niches. Modeling research and practice promoting sustainable and self-organizing ecosystems of this kind set the stage for redefining profit in terms of authentic wealth and value for life.

The adoptive transfer of T cells redirected to tumor-associated antigens via transgenic expression of chimeric antigen receptors (CARs) has produced tumor responses, even in patients with refractory diseases. To target pancreatic cancer, we generated CAR T cells directed against prostate stem cell antigen (PSCA) and demonstrated specific tumor lysis. However, pancreatic tumors employ immune evasion strategies such as the production of inhibitory cytokines, which limit CAR T cell persistence and function. Thus, to protect our cells from the immunosuppressive cytokine IL-4, we generated an inverted cytokine receptor in which the IL-4 receptor exodomain was fused to the IL-7 receptor endodomain (4/7 ICR). Transgenic expression of this molecule in CAR-PSCA T cells should invert the inhibitory effects of tumor-derived IL-4 and instead promote T cell proliferation. We now demonstrate the suppressed activity of CAR T cells in tumor-milieu conditions and the ability of CAR/ICR T cells to thrive in an IL-4-rich microenvironment, resulting in enhanced antitumor activity. Importantly, CAR/ICR T cells remained both antigen and cytokine dependent. These findings support the benefit of combining the 4/7 ICR with CAR-PSCA to treat pancreatic cancer, a PSCA-expressing tumor characterized by a dense immunosuppressive environment rich in IL-4.

Resume Objectif Concevoir des lignes directrices nationales en ce qui a trait a l'evaluation des preoccupations des femmes en matiere de sante sexuelle et a l'offre de soins de sante sexuelle aux femmes. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed, CINAHL et la Cochrane Library entre mai et octobre 2010, au moyen d'un vocabulaire controle (p. ex. « sexuality », « sexual dysfunction », « physiological », « dyspareunia ») et de mots cles appropries (p. ex. « sexual dysfunction », « sex therapy », « anorgasmia »). Les resultats ont ete restreints, dans la mesure du possible, aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction en matiere de langue n'a ete mise en oeuvre. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en decembre 2010. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Chacun des articles a ete analyse en vue d'en determiner la pertinence; le cas echeant, le texte integral a ete acquis. Les donnees obtenues ont ete analysees et evaluees par les membres du groupe d'experts mis sur pied par la Societe des obstetriciens et gynecologues du Canada. Valeurs La qualite des resultats a ete evaluee et les recommandations ont ete formulees au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau).

Pancreatic cancer (PaCA) is a deadly disease with few systemic therapeutic options. The head of the pancreas is the most innervated part and most common location of cancer. However, little is known about the contribution of the nerve-cancer interaction to facilitate pancreatic progression. To quantify PaCA axonogenesis, we used a 3-dimensional in vitro neurogenesis model. In addition, neurogenesis in human PaCA was analyzed using PGP9.5 immunohistochemistry, deconvolution imaging, and image segmentation and analysis. There was a significant increase of the total area of neurites in the in vitro coculture with dorsal root ganglia group than control. The nerve density in PaCA tissue was significantly higher than normal pancreatic tissue. To study the functional role of nerves in PaCA, male athymic nude (Nu-Nu) mice were divided into 3 groups: (A) animals were coinjected with MIA PaCa-2 cells and 20U/kg weight units of Botulinum toxin (Botox) (n=10); (B) first injected with Botox and 6weeks later MIA PaCa-2 cancer cells (n=4); and (C) control animals were injected with equivalent amounts of saline fluid (n=9). Animals were sacrificed 6weeks later. Tumor size and apoptotic count (terminal deoxynucleotidyl transferase dUTP nick-end labeling) were measured. Tumor size was decreased and apoptotic rate increased in Botox-treated PaCA. Our data indicate that neural microenvironment may play an important role in the progression of PaCA. It may lead to novel nerve-targeted coadjuvant therapies for PaCA.

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Chapter 8: Progestin-Only Contraception Summary Statements 15.Progestin implants have failure rates as low as permanent contraception. (II-2) 16.The use of a progestin implant immediately postpartum and post-abortion is an effective way of decreasing repeat pregnancy in adolescents and repeat abortions. (II-2) 17.The most common side effect of progestin-only contraceptive methods is menstrual cycle disturbances. (II-2) Amenorrhea is very common with depot medroxyprogesterone acetate and progestin implant use. (II-2) 18.The use of progestins given at contraceptive doses does not appear to increase the risk of venous thromboembolism, myocardial infarction, or stroke. (II-2) 19.The efficacy of progestin implants or depot medroxyprogesterone acetate is not decreased in overweight and obese women. (II-2) 20.Early weight gain with depot medroxyprogesterone acetate use is predictive of continued weight gain. (II-2) 21.Depot medroxyprogesterone acetate use is associated with a delay in resumption of ovulation. (II-2) 22.The use of depot medroxyprogesterone acetate (DMPA) is associated with a decrease in bone mineral density. This decrease is most rapid in the first 2 years of use and appears to be largely reversible once DMPA is discontinued. (I) There is no strong evidence that the use of DMPA causes osteoporosis (II-2) or increases the risk of fracture. (II-2) 23.The use of progestin-only preparations has not been shown to decrease breast milk production. (I) The small amounts of steroid hormones secreted in breast milk do not have an adverse effect on infant growth and development. (II-2) 24.Depot medroxyprogesterone acetate use is associated with a decreased risk of endometrial and ovarian cancer. (II-2) Recommendations 12.Progestin-only methods of contraception should be considered in women with medical conditions where estrogen is contraindicated or less appropriate, such as women who are recently postpartum, breastfeeding, or in smokers over age 35. (III-A) 13.There should be no restriction on the use of depot medroxy-progesterone acetate (DMPA), including duration of use, among women of reproductive age who are otherwise eligible to use the method. The overall risks and benefits of continuing DMPA use should be discussed with DMPA users at regular intervals throughout the course of treatment. (III-A) 14.Counselling regarding menstrual cycle disturbances should be done prior to initiating a progestin-only method of contraception. (I-A) 15.Health care providers should inform patients of the potential effects of depot medroxyprogesterone acetate on bone mineral density and counsel them on "bone health," including calcium and vitamin D supplementation, smoking cessation, weight-bearing exercise, and decreased alcohol and caffeine consumption. (III-A) 16.If prolonged and/or frequent bleeding occurs in users of progestin-only contraceptives, pregnancy, sexually transmitted infection, and genital pathology should be ruled out. (III-B) 17.Ectopic pregnancy should be ruled out if a pregnancy occurs in a woman using a progestin-only method of contraception. (III-A)

Resume Objectif Fournir des lignes directrices aux fournisseurs de soins quant a l'utilisation de modes de contraception pour la prevention de la grossesse et quant a la promotion d'une sexualite saine. Issues Orientation des praticiens canadiens en ce qui concerne l'efficacite globale, le mecanisme d'action, les indications, les contre-indications, les avantages n'etant pas lies a la contraception, les effets indesirables, les risques et le protocole de mise en œuvre des modes de contraception abordes; planification familiale dans le contexte de la sante sexuelle et du bien-etre general; methodes de counseling en matiere de contraception; et accessibilite et disponibilite des modes de contraception abordes au Canada. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d'un vocabulaire controle (p. ex. contraception , sexuality , sexual health ) et de mots cles (p. ex. contraception , family planning , hormonal contraception , emergency contraception ) appropries. Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 1994 et janvier 2015. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en juin 2015. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Chapitre 8 : Contraception a progestatif seul Declarations sommaires 15.Les implants de progestatif comptent des taux d'echec aussi faibles que ceux de la contraception permanente. (II-2) 16.L'insertion d'un implant immediatement a la suite d'un accouchement ou d'un avortement constitue une facon efficace d'abaisser les taux de nouvelle grossesse chez les adolescentes et de nouvel avortement. (II-2) 17.Les perturbations du cycle menstruel constituent l'effet indesirable le plus courant des modes de contraception a progestatif seul. (II-2) L'amenorrhee est tres courante dans le cadre de l'utilisation d'acetate de medroxyprogesterone-retard et d'implants de progestatif. (II-2) 18.L'utilisation de progestatifs administres selon des doses contraceptives ne semble pas accroitre le risque de thromboembolie veineuse, d'infarctus du myocarde ou d'accident vasculaire cerebral. (II-2) 19.L'efficacite des implants de progestatif (ou de l'acetate de medroxyprogesterone) n'est pas amoindrie chez les femmes obeses ou presentant une surcharge ponderale. (II-2) 20.La constatation d'un gain ponderal precoce dans le cadre de l'utilisation d'acetate de medroxyprogesterone-retard permet de predire la poursuite du gain ponderal. (II-2) 21.L'utilisation d'acetate de medroxyprogesterone-retard est associee a un delai quant a la reprise de l'ovulation. (II-2) 22.L'utilisation d'acetate de medroxyprogesterone-retard est associee a une baisse de la densite minerale osseuse. Cette baisse atteint sa rapidite maximale au cours des deux premieres annees d'utilisation et semble etre largement reversible a la suite de l'abandon du traitement a l'acetate de medroxyprogesterone-retard. (I) Nous ne disposons pas de donnees probantes solides indiquant que l'utilisation d'acetate de medroxyprogesterone-retard cause l'osteoporose (II-2) ou qu'elle entraine une hausse du risque de fracture. (II-2) 23.Il n'a pas ete demontre que l'utilisation de preparations a progestatif seul entraine une baisse de la production de lait maternel. (I) Les petites quantites d'hormones steroidiennes secretees dans le lait maternel n'exercent pas un effet indesirable sur la croissance et le developpement du nouveau-ne. (II-2) 24.L'utilisation d'acetate de medroxyprogesterone-retard est associee a une baisse des risques de cancer de l'endometre et de cancer de l'ovaire. (II-2) Recommandations 12.Le recours a des modes de contraception a progestatif seul devrait etre envisage chez les femmes qui presentent des troubles medicaux dans le cadre desquels la prise d'œstrogenes est contre-indiquee ou moins souhaitable, comme dans le cas des femmes qui ont recemment connu un accouchement, qui allaitent ou qui fument et qui sont âgees de plus de 35 ans. (III-A) 13.Aucune restriction ne devrait etre imposee quant a l'utilisation d'acetate de medroxyprogesterone-retard (y compris en ce qui a trait a la duree d'utilisation) chez les femmes en âge de procreer qui sont autrement admissibles a l'utilisation de ce mode de contraception. Les risques et les avantages globaux de la poursuite de l'utilisation d'acetate de medroxyprogesterone-retard devraient faire l'objet de discussions avec les utilisatrices a intervalles reguliers tout au long du traitement. (III-A) 14.Des services de counseling traitant des perturbations du cycle menstruel devraient etre offerts avant la mise en œuvre d'un mode de contraception a progestatif seul. (I-A) 15.Les fournisseurs de soins devraient aviser leurs patientes des effets potentiels de l'acetate de medroxyprogesterone-retard sur la densite minerale osseuse et leur offrir des conseils en matiere de « sante osseuse » (y compris en ce qui concerne la supplementation en calcium et en vitamine D, l'abandon du tabagisme, la pratique d'exercices de port de poids et l'attenuation de la consommation d'alcool et de cafeine). (III-A) 16.En presence de saignements prolonges et/ou frequents chez des utilisatrices de contraceptifs a progestatif seul, la presence d'une grossesse, d'une infection transmissible sexuellement ou d'une pathologie genitale devrait etre ecartee. (III-B) 17.La possibilite d'une grossesse ectopique doit etre ecartee lorsqu'une grossesse en vient a se manifester chez une femme qui utilise un mode de contraception a progestatif seul. (III-A)

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Chapter 7: Intrauterine Contraception Summary Statements 1.Intrauterine contraceptives are as effective as permanent contraception methods. (II-2) 2.The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I) 3.Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2) 4.The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5.The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6.Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2) 7.Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2) 8.In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9.Intrauterine contraceptives do not increase the risk of infertility. (II-2) 10.Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11.Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12.Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2) 13.Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14.Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I) Recommendations 1.Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A) 2.In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3.Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4.Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A) 5.A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A) 6.Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B) 7.In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8.In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B) 9.Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10.Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)

Resume Objectif Fournir des lignes directrices aux fournisseurs de soins quant a l'utilisation de modes de contraception pour la prevention de la grossesse et quant a la promotion d'une sexualite saine. Issues Orientation des praticiens canadiens en ce qui concerne l'efficacite globale, le mecanisme d'action, les indications, les contre-indications, les avantages n'etant pas lies a la contraception, les effets indesirables, les risques et le protocole de mise en œuvre des modes de contraception abordes; planification familiale dans le contexte de la sante sexuelle et du bien-etre general; methodes de counseling en matiere de contraception; et accessibilite et disponibilite des modes de contraception abordes au Canada. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d'un vocabulaire controle (p. ex. contraception , sexuality , sexual health ) et de mots cles (p. ex. contraception , family planning , hormonal contraception , emergency contraception ) appropries. Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 1994 et janvier 2015. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en juin 2015. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau).

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general wellbeing; contraceptive counselling methods; and access to and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Clinical trials show that opioid agonist therapy (OAT) with methadone or buprenorphine is more effective than behavioral treatments, but state policymakers remain ambivalent about covering OAT for long periods. We used Medicaid claims for 52,278 Massachusetts Medicaid beneficiaries with a diagnosis of opioid abuse or dependence between 2004 and 2010 to study associations between use of methadone, buprenorphine or other behavioral health treatment without OAT, and time to relapse and total healthcare expenditures. Cox Proportional Hazards ratios for patients treated with either methadone or buprenorphine showed approximately 50% lower risk of relapse than behavioral treatment without OAT. Expenditures per month were from $153 to $233 lower for OAT episodes compared to other behavioral treatment. Co-occurring alcohol abuse/dependence quadrupled the risk of relapse, other non-opioid abuse/dependence doubled the relapse risk and severe mental illness added 80% greater risk compared to those without each of those disorders. Longer current treatment episodes were associated with lower risk of relapse. Relapse risk increased as prior treatment exposure increased but prior treatment was associated with slightly lower total healthcare expenditures. These findings suggest that the effectiveness of OAT that has been demonstrated in clinical trials persists at the population level in a less controlled setting and that OAT is associated with lower total healthcare expenditures compared to other forms of behavioral treatment for patients with opioid addiction. Co-occurring other substance use and mental illness exert strong influences on cost and risk of relapse, suggesting that individuals with these conditions need more comprehensive treatment.

The U.S. Environmental Protection Agency (EPA) has recently realigned its research enterprise around the concept of sustainability, including improving understanding of benefits derived from ecosystems. We provide an example of how EPA is applying structured decision-making (SDM) as a framework for guiding development of scientific information, data, and models to support watershed and marine-based management in coastal communities. In particular, we have been using the Driver–Pressure–State–Impact–Response (DPSIR) model as a tool in the SDM process to identify and assemble a broadly applicable suite of information with relevancy for coastal management, including 1) development of conceptual models to clarify the decision context, 2) identification of measurements of ecosystem attributes, ecosystem goods and services, and their connection to stakeholder objectives, 3) elaboration of potential decision alternatives, and 4) identification of ecosystem production and valuation functions for modeling consequences of decision alternatives on benefits derived from coral reefs. Finally, we overview how this information is being applied for two case studies: development of water quality criteria and watershed management to protect coastal resources. We posit that applying a systems thinking framework, such as DPSIR, within a structured decision-making approach will better enable marine ecosystem managers to utilize scientific information toward more sustainable decision-making.

In gaining a better understanding of how to characterise human response, essential to improved person-centred care and other situations where human factors are crucial, recent work has attempted to link metrological (resolution, classification effectiveness) and psychometric (Rasch) characterisation of Man as a Measurement Instrument. The present work offers a more detailed account of these investigations following our first preliminary conference report, continuing a study of elementary tasks, such as counting dots, where one knows independently the expected value because the measurement object (collection of dots) is prepared in advance. The analysis is compared and contrasted with recent approaches to this problem by others, for instance using signal error fidelity and loss functions. Independent sources of measurement uncertainty, such as under-estimation of scores, are distinguished from separate estimates of task challenge and individual counting ability, and accounted for in estimates of reliability of the various measures.

Objectives Lack of providers is a barrier to accessing abortion in Canada. The factors influencing the number of abortion providers are poorly understood. In this study, we assessed the attitudes and intentions of medical students towards abortion training and provision to gain insight into the future supply of abortion providers. Methods We surveyed first, second, and third year medical students at an Ontario university to determine their intentions to train in and provide abortion services during different stages of training and in future practice. We assessed students' attitudes and intentions towards training in and providing abortions, their perceptions of social support, their perceived ability to receive training in and to provide abortion services, and their attitudes towards the legality of abortion. Results Surveys were completed by 337 of 508 potential respondents (66.7%). The responses indicated that the students in the survey held relatively positive attitudes towards the legality and availability of abortion in Canada. Respondents had significantly more positive attitudes towards first trimester medical abortions (and a greater intention to provide them) than towards second trimester surgical abortions. Thirty-five percent of students planned to enter a specialty in which they could perform abortions, but fewer than 30% of these students planned to provide any type of abortion. Intentions to provide abortions were correlated with positive attitudes toward abortion in general and greater perceived social support for abortion provision. Conclusion A small proportion of students sampled intended both to enter a specialty in which abortion would be within the scope of practice and to provide abortion services. Lack of perceived social support for providing abortions and the perceived inability to obtain abortion training or to logistically provide abortions were identified as two potentially modifiable barriers to abortion provision. We propose increasing education on abortion provision and creating policies to promote medical abortion as a method of improving access to abortion across Canada.